Evaluation of methods for linking household and health care provider data to estimate effective coverage of management of child illness: results of a pilot study in Southern Province, Zambia.

BACKGROUND: Existing population-based surveys have limited accuracy for estimating the coverage and quality of management of child illness. Linking household survey data with health care provider assessments has been proposed as a means of generating more informative population-level estimates of effective coverage, but methodological issues need to be addressed. METHODS: A 2016 survey estimated effective coverage of management of child illness in Southern Province, Zambia, using multiple methods for linking temporally and geographically proximate household and health care provider data. Mothers of children <5 years were surveyed about seeking care for child illness. Information on health care providers' capacity to manage child illness, or structural quality, was assessed using case scenarios and a tool modeled on the WHO Service Availability and Readiness Assessment (SARA). Each sick child was assigned the structural quality score of their stated (exact-match) source of care. Effective coverage was calculated as the average structural quality experienced by all sick children. Children were also ecologically linked to providers using measures of geographic proximity, with and without data on non-facility providers, to assess the effects of these linking methods on effective coverage estimates. RESULTS: Data were collected on 83 providers and 385 children with fever, diarrhea, and/or symptoms of ARI in the preceding 2 weeks. Most children sought care from government facilities or community-based agents (CBAs). Effective coverage of management of child illness estimated through exact-match linking was approximately 15-points lower in each stratum than coverage of seeking skilled care due to providers' limited structural quality. Estimates generated using most measures of geographic proximity were similar to the exact-match estimate, with the exception of the kernel density estimation method in the urban area. Estimates of coverage in rural areas were greatly reduced across all methods using facility-only data if seeking care from CBAs was treated as unskilled care. CONCLUSIONS: Linking household and provider data may generate more informative estimates of effective coverage of management of child illness. Ecological linking with provider data on a sample of all skilled providers may be as effective as exact-match linking in areas with low variation in structural quality within a provider category or minimal provider bypassing.

Mathematical models of human mobility of relevance to malaria transmission in Africa.

As Africa-wide malaria prevalence declines, an understanding of human movement patterns is essential to inform how best to target interventions. We fitted movement models to trip data from surveys conducted at 3-5 sites throughout each of Mali, Burkina Faso, Zambia and Tanzania. Two models were compared in terms of their ability to predict the observed movement patterns - a gravity model, in which movement rates between pairs of locations increase with population size and decrease with distance, and a radiation model, in which travelers are cumulatively "absorbed" as they move outwards from their origin of travel. The gravity model provided a better fit to the data overall and for travel to large populations, while the radiation model provided a better fit for nearby populations. One strength of the data set was that trips could be categorized according to traveler group - namely, women traveling with children in all survey countries and youth workers in Mali. For gravity models fitted to data specific to these groups, youth workers were found to have a higher travel frequency to large population centers, and women traveling with children a lower frequency. These models may help predict the spatial transmission of malaria parasites and inform strategies to control their spread.

Validity of maternal report of care-seeking for childhood illness.

BACKGROUND: Accurate data on care-seeking for child illness are needed to improve public health programs and reduce child mortality. The accuracy of maternal report of care-seeking for child illness as collected through household surveys has not been validated. METHODS: A 2016 survey compared reported care-seeking against a gold-standard of health care provider documented care-seeking events among a random sample of mothers of children <5 years in Southern Province, Zambia. Enrolled children were assigned cards with unique barcodes. Seventy-five health care providers were given smartphones with a barcode reader and instructed to scan the cards of participating children seeking care at the source, generating an electronic record of the care-seeking event. Additionally, providers gave all caregivers accessing care for a child <5 years provider-specific tokens used to verify the point of care during the household survey. Reported care-seeking events were ascertained in each household using a questionnaire modeled off the Zambia Demographic and Health Survey (DHS) / Multiple Indicator Cluster Survey (MICS). The accuracy of maternal report of care-seeking behavior was estimated by comparing care-seeking events reported by mothers against provider-documented events. RESULTS: Data were collected on 384 children with fever, diarrhea, and/or symptoms of ARI in the preceding 2 weeks. Most children sought care from government facilities or community-based agents (CBAs). We found high sensitivity (Rural: 0.91, 95% confidence interval CI 0.84-0.95; Urban: 0.98, 95% CI 0.92-0.99) and reasonable specificity (Rural: 0.71, 95% CI 0.57-0.82; Urban: 0.76, 95% CI 0.62-0.85) of maternal report of care-seeking for child illness by type of provider. Maternal report of any care-seeking and seeking care from a skilled provider had slightly higher sensitivity and specificity. Seeking care from a traditional practitioner was associated with lower odds of accurately reporting the event, while seeking care from a government provider was associated with greater odds of accurate report. The measure resulted in a slight overestimation of true care-seeking behavior in the study population. CONCLUSIONS: Maternal report is a valid measure of care-seeking for child illness in settings with high utilization of public sector providers. The study findings were limited by the low diversity in care-seeking practices for child illness and the exclusion of shops.

Effects of Airborne Particulate Matter on Respiratory Health in a Community near a Cement Factory in Chilanga, Zambia: Results from a Panel Study.

We conducted a panel study to investigate seasonal variations in concentrations of airborne PM2.5 and PM10 and the effects on respiratory health in a community near a cement factory; in Chilanga; Zambia. A panel of 63 and 55 participants aged 21 to 59 years from a community located at the edge of the factory within 1 km and a control community located 18 km from the factory respectively; were followed up for three climatic seasons July 2015 to February 2016. Symptom diary questionnaires were completed and lung function measurements taken daily for 14 days in each of the three climatic seasons. Simultaneously, PM2.5 and PM10 concentrations in ambient air were monitored at a fixed site for each community. Mean seasonal concentrations of PM2.5 and PM10 ranged from 2.39-24.93 µg/m3 and 7.03-68.28 µg/m³ respectively in the exposed compared to the control community 1.69-6.03 µg/m³ and 2.26-8.86 µg/m³. The incident rates of reported respiratory symptoms were higher in the exposed compared to the control community: 46.3 vs. 13.8 for cough; 41.2 vs. 9.6 for phlegm; 49.0 vs.12.5 for nose; and 13.9 vs. 3.9 for wheeze per 100 person-days. There was a lower performance on all lung indices in the exposed community compared to the control; overall the mean FEV1 (forced expiratory volume in one second) and FVC (forced vital capacity) predicted percentage for the exposed was six and four percentage points lower than the control. Restriction of industrial emissions coupled with on-going monitoring and regulatory enforcement are needed to ensure that PM (airborne particulate matter) levels in the ambient air are kept within recommended levels to safeguard the respiratory health of nearby community residents.

Key traveller groups of relevance to spatial malaria transmission: a survey of movement patterns in four sub-Saharan African countries.

BACKGROUND: As malaria prevalence declines in many parts of the world due to widescale control efforts and as drug-resistant parasites begin to emerge, a quantitative understanding of human movement is becoming increasingly relevant to malaria control. However, despite its importance, significant knowledge gaps remain regarding human movement, particularly in sub-Saharan Africa. METHODS: A quantitative survey of human movement patterns was conducted in four countries in sub-Saharan Africa: Mali, Burkina Faso, Zambia, and Tanzania, with three to five survey locations chosen in each country. Questions were included on demographic and trip details, malaria risk behaviour, children accompanying travellers, and mobile phone usage to enable phone signal data to be better correlated with movement. A total of 4352 individuals were interviewed and 6411 trips recorded. RESULTS: A cluster analysis of trips highlighted two distinct traveller groups of relevance to malaria transmission: women travelling with children (in all four countries) and youth workers (in Mali). Women travelling with children were more likely to travel to areas of relatively high malaria prevalence in Mali (OR = 4.46, 95% CI = 3.42-5.83), Burkina Faso (OR = 1.58, 95% CI = 1.23-1.58), Zambia (OR = 1.50, 95% CI = 1.20-1.89), and Tanzania (OR = 2.28, 95% CI = 1.71-3.05) compared to other travellers. They were also more likely to own bed nets in Burkina Faso (OR = 1.77, 95% CI = 1.25-2.53) and Zambia (OR = 1.74, 95% CI = 1.34 2.27), and less likely to own a mobile phone in Mali (OR = 0.50, 95% CI = 0.39-0.65), Burkina Faso (OR = 0.39, 95% CI = 0.30-0.52), and Zambia (OR = 0.60, 95% CI = 0.47-0.76). Malian youth workers were more likely to travel to areas of relatively high malaria prevalence (OR = 23, 95% CI = 17-31) and for longer durations (mean of 70 days cf 21 days, p < 0.001) compared to other travellers. CONCLUSIONS: Women travelling with children were a remarkably consistent traveller group across all four countries surveyed. They are expected to contribute greatly towards spatial malaria transmission because the children they travel with tend to have high parasite prevalence. Youth workers were a significant traveller group in Mali and are expected to contribute greatly to spatial malaria transmission because their movements correlate with seasonal rains and hence peak mosquito densities. Interventions aimed at interrupting spatial transmission of parasites should consider these traveller groups.

Antibiotic prescribing practices for patients with fever in the transition from presumptive treatment of malaria to 'confirm and treat' in Zambia: a cross-sectional study.

OBJECTIVES: To evaluate antibiotic use among patients presenting to primary healthcare facilities with febrile illness in Zambia. METHODS: We analysed data from a 2011 nationwide cross-sectional health facility survey of routine malaria case management in Zambia. Patient consultation observation and medical record charts were used to calculate the proportion of febrile patients who were prescribed antibiotics, stratified by symptoms, health workers' diagnosis and malaria test results. Logistic regression was used to identify factors affecting antibiotic prescribing behaviour. RESULTS: Of 872 patients presenting with fever, 651 (74.6%) were tested for malaria. Among those tested, 608 (93.4%) had analysable results; 230 (37.8%) had positive results. Antibiotics were prescribed to 69/230 (30.0%), 247/378 (65.3%) and 132/221 (59.7%) of those who tested positive, negative and those 'not tested', respectively. Furthermore, antibiotics were prescribed to 36/59 (61.0%) and 242/322 (75.1%) of those diagnosed with diarrhoea and upper respiratory tract infection (URTI), respectively. Among patients prescribed any antibiotic, concurrent antimalarial prescribing occurred in 66/69 (95.6%), 32/247 (12.9%) and 19/132 (14.4%) for those with positive results, negative results and 'not tested', respectively. Respiratory symptoms, diagnosis of URTI, malaria or skin disease and level of health care in the health delivery system were associated with antibiotic prescribing. CONCLUSIONS: Testing positive for malaria or receiving a malaria diagnosis was associated with reduced antibiotic prescribing, while testing negative, not being tested or a diagnosis of URTI resulted in higher rates of antibiotic prescribing. There is a need for improving diagnostic capacity for non-malaria causes of febrile illness at healthcare delivery points and limiting antibiotic use to patients with definite bacterial infections.

Prevalence and determinants of mucous membrane irritations in a community near a cement factory in Zambia: a cross sectional study.

Exposure to cement dust has been associated with deleterious health effects in humans. This study investigated whether residing near a cement factory increases the risk of irritations to the mucous membranes of the eyes and respiratory system. A cross sectional study was conducted in Freedom Compound, a community bordering a cement factory in Chilanga, Zambia and a control community, Bauleni, located 18 km from the cement plant. A modified American Thoracic Society questionnaire was administered to 225 and 198 respondents aged 15-59 years from Freedom and Bauleni, respectively, to capture symptoms of the irritations. Respondents from Freedom Compound, were more likely to experience the irritations; adjusted ORs 2.50 (95% CI: 1.65, 3.79), 4.36 (95% CI (2.96, 6.55)) and 1.94 (95% CI (1.19, 3.18)) for eye, nose and sinus membrane irritations respectively. Cohort panel studies to determine associations of cement emissions to mucous membrane irritations and respiratory symptoms, coupled with field characterization of the exposure are needed to assess whether the excess prevalence of symptoms of mucous membrane irritations observed in Freedom compound are due to emissions from the cement factory.

Documenting malaria case management coverage in Zambia: a systems effectiveness approach.

BACKGROUND: National malaria control programmes and their partners must document progress associated with investments in malaria control. While documentation has been achieved through population-based surveys for most interventions, measuring changes in malaria case management has been challenging because the increasing use of diagnostic tests reduces the denominator of febrile children who should receive anti-malarial treatment. Thus the widely used indicator, "proportion of children under five with fever in the last two weeks who received anti-malarial treatment according to national policy within 24 hours from onset of fever" is no longer relevant. METHODS: An alternative sequence of indicators using a systems effectiveness approach was examined using data from nationally representative surveys in Zambia: the 2012 population-based Malaria Indictor Survey (MIS) and the 2011 Health Facility Survey (HFS). The MIS measured fever treatment-seeking behaviour among 972 children under five years (CU5) and 1,848 people age five years and above. The HFS assessed management of 435 CU5 and 429 people age five and above with fever/history of fever seeking care at 149 health facilities. Consultation observation and exit interviews measured use of diagnostic tests, artemisinin combination therapy (ACT) prescription, and patient comprehension of prescribed regimens. RESULTS: Systems effectiveness for malaria case management among CU5 was estimated as follows: [100% ACT efficacy] x [55% fever treatment-seeking from an appropriate provider (MIS)] x [71% malaria blood testing (HFS)] x [86% ACT prescription for positive cases (HFS)] x [73% patient comprehension of prescribed ACT drug regimens (HFS)] = 25%. Systems effectiveness for malaria case management among people age five and above was estimated at 15%. CONCLUSIONS: Tracking progress in malaria case management coverage can no longer rely solely on population-based surveys; the way forward likely entails household surveys to track trends in fever treatment-seeking behaviour, and facility/provider data to track appropriate management of febrile patients. Applying health facility and population-based data to the systems effectiveness framework provides a cogent and feasible approach to documenting malaria case management coverage and identifying gaps to direct program action. In Zambia, this approach identified treatment-seeking behaviour as the largest contributor to reduction in systems effectiveness for malaria case management.

Improved diagnostic testing and malaria treatment practices in Zambia.

CONTEXT: Improving the accuracy of malaria diagnosis with rapid antigen-detection diagnostic tests (RDTs) has been proposed as an approach for reducing overtreatment of malaria in the current era of widespread implementation of artemisinin-based combination therapy in sub-Saharan Africa. OBJECTIVE: To assess the association between use of microscopy and RDT and the prescription of antimalarials. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional, cluster sample survey, carried out between March and May 2006, of all outpatients treated during 1 working day at government and mission health facilities in 4 sentinel districts in Zambia. MAIN OUTCOME MEASURE: Proportions of patients undergoing malaria diagnostic procedures and receiving antimalarial treatment. RESULTS: Seventeen percent of the 104 health facilities surveyed had functional microscopy, 63% had RDTs available, and 73% had 1 or more diagnostics available. Of patients with fever (suspected malaria), 27.8% (95% confidence interval [CI], 13.1%-42.5%) treated in health facilities with malaria diagnostics were tested and 44.6% had positive test results. Of patients with negative blood smear results, 58.4% (95% CI, 36.7%-80.2%) were prescribed an antimalaria drug, as were 35.5% (95% CI, 16.0%-55.0%) of those with a negative RDT result. Of patients with fever who did not have diagnostic tests done, 65.9% were also prescribed antimalarials. In facilities with artemether-lumefantrine in stock, this antimalarial was prescribed to a large proportion of febrile patients with a positive diagnostic test result (blood smear, 75.0% [95% CI, 51.7%-98.3%]; RDT, 70.4% [95% CI, 39.3%-100.0%]), but also to some of those with a negative diagnostic test result (blood smear, 30.4% [95% CI, 8.0%-52. 9%]; RDT, 26.7% [95% CI, 5.7%-47.7%]). CONCLUSIONS: Despite efforts to expand the provision of malaria diagnostics in Zambia, they continue to be underused and patients with negative test results frequently receive antimalarials. Provision of new tools to reduce inappropriate use of new expensive antimalarial treatments must be accompanied by a major change in clinical treatment of patients presenting with fever but lacking evidence of malaria infection.